Certificate of Origin

Shipper Name and Address Forwarding Agent - References

Consignee Name and Address Notify Party

Exporting Carrier Country of Manufacture

Total Number of Packages Date of Export

Quantity / Weight (kg)

Marks & Numbers Commodity Description
Unit of Measure Gross Net

These commodities, technology or software were exported from the United States of America in accordance with the Export
Administration Regulations. Diversion contrary to U.S. law prohibited.

Dated at ____________ on the ______ day of _______________ , 20 ____ . Signature of Notary: ________________________

Sworn to before me this _____ day of _______________ , 20 _____ . Signature of Notary: ______________________________

The _________________________ , a recognized Chamber of Commerce under the laws of the State of _____________________

has examined the manufacturers invoice or shippers affidavit concerning the origin of the merchandise and, according to the best

of its knowledge and belief, finds that the products named originated in the _____________________________ .

Secretary: __________________________________________________
FXF - SL235/503